Lean Six Sigma for Intravenous Therapy Optimization: A Hospital Use of Lean Thinking to Improve Occlusion Management - Nexus ...
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O R I G I N A L A R T I C L E
Lean Six Sigma for Intravenous Therapy
Optimization: A Hospital Use of Lean Thinking
to Improve Occlusion Management
Lee Steere, RN, CRNI, VA-BC
Marc Rousseau, MBA, RPH
Lisa Durland, MS, RPH
Hartford Hospital, Hartford, CT
Abstract
Background: Continual improvement is a necessary part of hospital culture. This occurs by identifying opportunities
for improvement that influence efficiency while saving money.
Methodology: An investigation of intravenous device-related practices was performed by the nurses of the intravenous
access team, pharmacy, and hospital operations at Hartford Hospital using Lean Six Sigma methodology. Central
venous access device occlusion and tissue plasminogen activator variability was identified. Using observation,
measurement of performance, and root cause analysis, the hospital’s practices, policies, and equipment were evaluated
for the process of occlusion management. The team utilized a Six Sigma strategy employing the elements define,
measure, analyze, improve, and control, which is a disciplined, data-driven methodology that focuses on eliminating
defects (waste). Interventions initiated based on the assessment performed by the team using the define, measure,
analyze, improve, and control approach included replacement of negative displacement needleless connectors with
antireflux needleless connectors and specialty team assessment before tissue plasminogen activator use.
Results: Over the course of the 26-month study, Hartford Hospital experienced a 69% total reduction in tissue
plasminogen activator use representing a total 26-month savings of $107,315. Other cost savings were reflected in areas
of flushing, flushing disposables, and in a decrease in needleless connector consumption. Central line-associated
bloodstream rates fell 36% following the intervention as an unexpected secondary gain, resulting in further savings
related to treating this nonreimbursable hospital-acquired condition.
Conclusions: This study examined the influence of using Lean Thinking and Six Sigma methodology as a tool in saving
hospital money, resulting in better patient outcomes.
Keywords: central venous catheter, cost savings, lean six sigma
Introduction time during the IV treatment processes.7,8 Intraluminal throm-
A
mong the most frequent complications associated with botic catheter occlusion, a common noninfectious complication,
central venous access devices (CVADs) is catheter oc- is associated with negative outcomes of loss of patency (43%),
clusion, ranging from 3%-79%.1-4 Thrombotic formations device replacement (29%), device removal (14%), and hospi-
on a CVAD are a natural physiological process in response to tal visits (15%) that all delay or disrupt the treatment process,
the insertion of foreign material into the body. Immediately upon slow a patient’s progress toward therapeutic goals, and in-
insertion of an intravenous (IV) catheter, cells attach to the surface crease length of hospital stay and cost of care.1,2,9,10
forming a fibrin coating.5,6 This body response occurs soon after Peripherally inserted central catheters (PICCs), a type of
insertion and may develop around and within a catheter at any CVAD, have a higher incidence of occlusion than other chest-
inserted central catheters potentially due to factors such as
insertion into smaller peripheral veins, larger surface area, use
of 3F-6F sizes with multiple lumens, and small catheter
Correspondence concerning this article should be addressed to diameter.2,11-16 Activities associated with PICCs for administra-
Lee.Steere@hhchealth.org. tion of IV medications and solutions require flushing, aspiration
https://doi.org/10.1016/j.java.2018.01.002 of blood, and connection and disconnection of needleless con-
Copyright © 2018 Association for Vascular Access. Published nectors (NCs) causing pressure changes within the catheter that
by Elsevier Inc. All rights reserved. result in venous blood cell deposits within the lumen of the
42 | JAVA | Vol 23 No 1 | 2018
catheter known as reflux. Reflux is associated with both me- • Control by building a system of checks and adjustments
chanical and physiological pressure changes that force blood for ongoing improvement in the process, protocols, prac-
into the catheter lumen, leaving blood deposits contributing to tices, products, and patient outcomes (5Ps) of IV therapy.
the incidence of catheter occlusion.17,18
Reflux of blood into the terminal end of a catheter is a cause The Hartford IV Team and stakeholders incorporated inves-
of catheter occlusion.19 Patient movements, muscle flexing, and tigation of the 5Ps of IV therapy for insertion and management
coughing all cause pressure changes and reflux within the cath- of vascular access devices. This process used the 5Ps as a tool
eter. As the catheter is manipulated, blood is intermittently pulled to assist in differentiating value-added actions from nonvalue-
back into the catheter.19,20 These deposits of blood on the cath- added actions. By using the 5Ps systematic approach, waste and
eter may be cleared, somewhat, with saline flushing.21-23 When variability became obvious and detectable.
catheter lumen flushing is inadequate or blood protein depos- The LSS program at Hartford continued with agreement from
its completely or partially block the terminal end of the catheter, the stakeholders from the supply chain and IV Team and from
these occlusions to the terminal end of the catheter may prevent pharmacy, all committed to performance improvement. Infu-
blood sampling and the infusion of fluids.10,21,24,25 sion treatment with catheters in our facility represents more than
90% of our acute care hospital patients and CVADs are in use
in approximately 50% of intensive care patients. Evaluating
Lean Six Sigma CVAD occlusion in terms of catheter function, flushing, and
Hartford Hospital in Hartford, Connecticut, is an 867-bed re- reflux had the potential to speed treatment and reduce occlu-
gional referral center and the largest Hospital in the Hartford sion complications. Wasted time, money, medical supplies, and
Health System. Lean Thinking and Six Sigma are 2 process im- pharmaceuticals and medications as well as logistics and nursing
provement methods the IV Team at Hartford Hospital costs were all components because they applied to reported events
implemented to improve infusion therapy practices. The Lean of occlusion. LSS focuses on reducing defects, variability, and
Six Sigma (LSS) process is used to implement positive change waste in current hospital IV access device practices.
by identifying inefficiencies, variables, process defects, and
waste.26-31 Specifically, LSS is a quality improvement method- Methods
ology that originated during the 1970s with the Toyota Motor The LSS methodology was used with the design indicated
Company and Toyota Production System.32 Much of the Toyota by the DMAIC process to define problems and goals, measure
Production System way of thinking is based on the work of W. activities and supplies, analyze results, and devise improve-
Edwards Deming.33 Deming taught, among other things, that ment strategies based on analysis and control throughout the
managers should stop depending on mass inspection to achieve process. A team of clinicians trained in LSS evaluated proce-
quality, and instead focus on improving the production process, dures from October 2014 to December 2016 to identify problems,
protocols, practices, and building quality into the product in the set goals to improve patient outcomes and reduce variability and
first place. LSS strives to pinpoint quality processes that correct waste resulting in long-term economic change. Goals and ob-
identified defects in a system. Simply put, LSS means using less jectives for each patient outcome and the variability and waste
to do more. sections were established for CVAD use, including heparin flush-
The Lean Thinking concept was used initially in our depart- ing, occlusion management, medication administration, CVAD
ment to improve the management of occluded CVADs. The replacement, and all associated supply costs.
hospital chose to study CVAD occlusion management while
working to promote savings in medications, supplies, and time. DMAIC Phases
This process allowed identification of variables that influ- The LSS framework for infusion therapy practices at our fa-
enced the way occlusions were managed (ie, assessment of cility began with a set of value-added actions and improvements
catheter function) and implement corrective actions that im- identified through the DMAIC process. The DMAIC method
proved patient delivery of treatment without administering was applied over 26 months as described in Tables 1–5. During
unnecessary medications. the define phase (Table 1), products and patient outcomes were
The LSS data-driven quality method at Hartford Hospital was evaluated for IV therapy. A refined literature review delved into
specifically guided by a programmed approach: defining, mea- subjects of catheter patency; thrombotic occlusion; risks asso-
suring, analyzing, improving, and controlling (DMAIC).34-36 ciated with tissue plasminogen activator (tPA) use; blood reflux;
The DMAIC phases: NCs; valves used in catheters and NCs; flush solution volume
and frequency; and CVAD indications, appropriate use, and tip
• Define opportunity for improvement, project goals, and position.10,17,20-22,37-51 The results of the literature review as-
patient requirements. sisted in guiding the analysis process.52,53 After defining key
• Measure pharmacy and medical supply consumption, concepts and associated activities the process moved into the
overall cost, and performance. measurement phase.
• Analyze the consumption data to determine root causes The measure phase (Table 2) of DMAIC distinguishes spe-
of variation and poor performance (defects). cific goals that quantify practices and processes needing
• Improve process performance by addressing and elimi- improvement. Measurement key areas included incidence of oc-
nating the root causes. clusion; drug use for occluded catheters; supply consumption
2018 | Vol 23 No 1 | JAVA | 43
Table 1. Phase I: Define Table 3. Phase III: Analysisa
1. Goals and objectives: Improve patient care, improve Analyze all data collected and map potential performance
patient outcomes, reduce waste, reduce IV variability, and opportunities
improve long-term economic results
Review new needleless connector technology
2. Define and review IV therapy 5Ps (IV processes, IV
Review literature regarding needleless connectors
protocols, IV practices, IV products, and IV patient
outcomes) Review infusion therapy evidence
3. Identify and target a specific hospital area (inpatient acute Root cause analysis of tissue plasminogen activator use by
care areas) where peripherally inserted central catheter registered nurses in intensive care unit
and central venous access devices are inserted and used
Registered nurses using tissue plasminogen activator
4. Focus on reducing pharmacy and medical supply waste without identifying cause of occlusion
by:
Prioritize opportunities to improve
a. Tissue plasminogen activator/tissue plasminogen acti-
vator use and associated cost, IV = Intravenous.
a
b. Flushing with heparin, Look for signs of IV waste, IV variability, and root causes of defects in our
c. Replacement and other costs associated with peripher- 5Ps.
ally inserted central catheters and central venous access
devices, and In the analysis phase (Table 3), information obtained during
d. Reducing medical supply consumption and medical supply the measure phase was mapped to demonstrate performance im-
costs provement opportunities as they applied to PICCs and all other
CVADs. Root cause analysis of each occurrence of CVAD oc-
IV = Intravenous. clusion incorporated the 5Ps. Each identified occlusion event
was accompanied by use of a thrombolytic medication (Cathflo;
specific to NCs; catheter volume and line days; and influence Genentech Laboratories, San Francisco, CA). Heparin and saline
on central line-associated bloodstream infections (CLABSIs). flushing practices, NC use, and associated supplies were in-
NCs and add-on peripheral supplies were also evaluated and cluded in the analysis. Understanding the outcomes of occlusion
quantified. The NCs in use at our facility included a negative and subsequent complications led researchers to establish an im-
displacement valve (Clave; ICU Medical, Inc, San Clemente, plementation plan that resulted in improvement.
CA). Collection of data, performed by the LSS clinicians and
IV Team, established baseline levels for improvement, com- Table 4. Phase IV: Improvea
parison, and analysis.
1. All nontunneled central venous access device catheters
shall be effectively assessed by a trained and skilled IV
Table 2. Phase II: Measurea Team RN for thrombotic occlusion before tissue
plasminogen activator is ordered
1. Obtained alteplase/tissue plasminogen activator
consumption data from pharmacy department 2. Nontunneled Central Venous Access Device Patency
Assessment Algorithm/Check List will be used to
2. Obtained prefilled heparin flushing syringe consumption determine root cause of occlusions
data
3. IV Team will receive all orders from intensive care nurses
3. Reviewed alteplase/tissue plasminogen activator and so proper and effective assessments can be achieved by a
heparin flushing 5Ps trained and skilled IV Team RN
4. IV Team began receiving daily tissue plasminogen 4. IV Team RN will order tissue plasminogen activator if
activator consumption report from pharmacy department appropriate
5. Obtained central line-associated bloodstream infection 5. Eliminate prefilled maintenance heparin flushing with
rates since 2007 evidence-based outcomes
6. Obtained central line days since 2007 data 6. Implement use of Anti-Reflux NC to reduce unintentional
7. Obtained needleless connector consumption data blood reflux into peripherally inserted central catheter and
central venous access devices and the associated risk of
IV = Intravenous. central line-associated bloodstream infection
a
We measured the 5Ps (IV processes, IV protocols, IV practices, IV prod-
ucts, and IV patient outcomes) against our defined goals and objectives VAT = Vascular access team.
a
to determine our current performance and quantify improvement Improve processes, protocols, practices, and products to eliminate waste,
opportunities. variability, and defects to improve patient care and outcomes.
44 | JAVA | Vol 23 No 1 | 2018Table 5. Phase V: Controla antireflux NCs (Nexus Medical TKO-6P; Nexus Medical LLC,
Lenexa, KS) designed to promote long-term patency.47 Out-
1. Nontunneled Central Venous Access Device Patency comes based on the antireflux NC change were reduced occlusion
Assessment Algorithm/Check List continues to deliver the and NC supply consumption. Each of these improvement mea-
control necessary to sustain the tissue plasminogen sures was projected to influence and reduce incidence of not
activator use reduction, improvement in patient outcomes, only occlusion, but also CLABSIs, reduce delays in treatment
and hospital economics of occluded catheters, and improve patient satisfaction by re-
ducing anxiety associated with nonfunctional CVADs.
2. The antireflux needleless connector automatically provides
In the control phase (Table 5), processes were applied to all
blood reflux protection to sustain the heparin and
5Ps to improve performance. The control process included imple-
corresponding tissue plasminogen activator use
menting an electronic medical record ordering process for tPA
reductions that improve patient care and hospital
that was hidden from view and application of an algorithm
economics
(Figure: Process Control for Occlusion Management) to eval-
3. Unintentional blood reflux is controlled via use of uate all CVAD occlusions. Over the 26-month period, all
antireflux needleless connector and the risk of infection stakeholders adopted these value-added actions and improve-
and central line-associated bloodstream infection is ments to maximize care practices for patients with IV access
reduced devices at Hartford Hospital.
a
Control processes, protocols, practices, and products to eliminate waste,
variability, and defects to improve patient care and outcomes.
Results
The number of inpatient acute care patients with CVAD oc-
clusions treated with tPA averaged 119 per month during 2014.
The improve phase (Table 4) addressed the specific practice Following implementation of an algorithm for appropriate use,
measures designed to meet the goals through the 5Ps. These mea- IV Team assessment, and antireflux NCs, the hospital achieved
sures included CVAD occlusion evaluation by the IV team before a 56% reduction to a new average annual baseline of 53 oc-
use of any thrombolytic medication. Compliance with flushing clusions per month for 2015. Further, the hospital achieved a
practices was measured as part of the processes instituted in the 61% reduction in tPA use for occlusions to a new average annual
previous phase. Negative displacement NCs were replaced with baseline of 47 occlusions per month for 2016 (Table 6). The
Table 6. Baseline 2014 With Negative Displacement Connector Changing to Anti-Reflux Connector 2015-2016
140
120
[VALUE] 2014 Average Baseline tPA Consumption 119/mth for Negative Displacement NC's
AVG
100
2015 Average Monthly tPA Consumption 53.18 for a 56% overall reduction from 2014 Baseline
80
TPA USAGE
2016 Average Monthly tPA Consumption 47.5 for a 61% overall reduction from 2014 Baseline
60
60
58 55
59
40 [VALUE] 46 47 45
AVG 51 42
38 37
31
20
0
BaselineBaseline Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2014 2015 2016 2016 2016 2016 2016 2016 2016 2016 2016 2016 2016 2016
2018 | Vol 23 No 1 | JAVA | 45Figure. Process flow for occlusion management. monthly range reflected a low of 31 occulusions per month to tion of 66,100 NCs (Table 7). The results of decreased occlusion, high of 60 occlusions per month. Decreased tPA consumption lower tPA use, and different NCs resulted in a positive annual (at a cost of $65 per 1-mg dose) resulted in savings for 2015 savings of $100,670. Antireflux NCs have been validated for a of $51,480 per year and for 2016 of $55,835 per year. Over the full 7-day use, rather than the twice-a-week change associated course of the 26-month study, Hartford Hospital experienced with the NC our facility previously used. This resulted in less a 69% total reduction in tPA use, representing a total 26- product use, less frequent CVAD line opening, and overall fewer month savings of $107,315 (Table 6). catheter occlusions. Following the intervention of new NCs there was a sus- Flushing practices were reported from October 2014 through tained medical supply reduction of 38%. The antireflux NCs December 2016. Heparin flush use volume at baseline (2014) showed a consumption reduction of 41%, which represented an was 52,522 syringes at a cost of $0.55 per syringe. Heparin annual decrease of 44,493 NCs. Costs associated with the pre- flush syringes were eliminated from the protocol while vious negative displacement connector was $105,064 annually prefilled 10-mL saline flush syringes remain. The elimination with a total consumption of 110,593 NCs. The replacement of heparin flushing syringes resulted in savings of $28,887 antireflux NCs cost $111,709 annually with a total consump- annually. 46 | JAVA | Vol 23 No 1 | 2018
Table 7. tPA Usage Baseline 2014 with Negative Displacement Connector Changing to Anti-Reflux Connector 2015-2016
In addition, the incidence of CLABSI as a secondary end point interruption16,54; negatively affects patient, clinical staff, and phar-
was evaluated. Retrospective data were combined with CLABSI macy staff; and results in economic loss for hospital
results to reflect decreasing incidence from 2007 to 2016. Eval- administration. Controls, such as assessment of catheter and in-
uation of the hospital intensive care unit CLABSI rate identified sertion sites by vascular access specialists; use of an algorithm
reductions from a 2007 calendar year high of 39 CLABSIs to to properly troubleshoot reported occlusions; instillation of tPA
a low of 9 CLABSIs in 2016. This change in CLABSIs repre- only after careful assessment by vascular access specialists; and
sented a 77% decline over 9 years. Even more notable, the ongoing education of clinical staff for productive flushing, ap-
hospital’s overall safety score fell from 0.475 to 0.301, a 36% plication of infection prevention measures, and aseptic technique
reduction, well below the national average of 0.437. for device management all worked together to improve patient
outcomes and reduce risk. Using a focused approach to process
Discussion improvement by combining Lean Thinking and Six Sigma, Hart-
Concerns over patient outcomes and the promotion of a culture ford Hospital achieved an increase in positive outcomes.
of safety drove Hartford Hospital to examine processes, pro- Improvement represented by this initiative was sustained re-
tocols, practices, and products along with outcome data collection. duction in CVAD occlusions and tPA use. Sustained improvement
Ongoing patient and catheter complications resulted in cathe- is supported by methods instituted by the IV Team. During this
ter failure, including occlusion, phlebitis, and infection. These intervention the focus was on 3 key drivers: patient satisfaction,
complications influenced function and efficacy in the delivery quality, and improvement. One measure of those drivers was the
of treatment and thus were targeted by our facility’s LSS health amount of tPA used during the prior 24 hours. The IV Team re-
care initiative. The findings from the LSS DMAIC reflected areas viewed every dose of tPA given via performance of an abbreviated
of variability in CVAD occlusion management, NCs, flushing root cause analysis. The IV Team verified that the algorithm had
with heparin, and incidence of CLABSI. been applied and if not, the Team investigated the deviation.
Application of LSS identified specific components of the Reasons for tPA administration was documented on a Pareto Chart
patient care process that were costly roadblocks to success. Cath- (depicting the frequency with which certain events occur), which
eter failure influences the ability to deliver treatment without allows better analysis of certain areas needing improvement. The
2018 | Vol 23 No 1 | JAVA | 47Timeline 1. Calendar Year Analysis and Interventions 2007 to 2016
Needleless Connector Change to An-Reflux, VAT all CVAD Dressings, Heparin
Alcohol Disinfecon Caps, Competency & Compliance Audits
39
HAI Commiee Formed - Policy Review and Analysis
40
VAT CVAD Removals, Phlebotomy Training for Blood Cultures
CVAD Rounding, Huddles, Eyes on Lines, Educaon
Quality Measures Changed to VAP, Rounding Reduced
37
36
35 34
Anmicrobial Dressing, CVAD Dressing Kits
CVAD Inseron Check List, IP Educaon
Crical Care-Catheter Related Blood Stream Infections
CVAD Rounding Resumed, USGPIV Training
30
30
Educaon. EPIC EMR Launched
25
Number of Infecons
20
17
16
Eliminaon
15
15
13
10 9
5
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Catheter Days 18,997 20,932 21,196 20,287 16,399 14,857 15,002 14,004
IV Team at Hartford Hospital continues to meet at 7:15 AM daily toring. This major change in hospital computer systems influenced
for a Lean huddle. Every idea generated by the staff of the IV the protocol and ordering process for tPA. There was concern that
Team is considered as a possible LSS project. our tPA use would rise, but initiatives hardwired during the LSS
The NC change and heparin elimination have continued to result phases were consistently maintained. No increase in tPA use re-
in reductions in CLABSI. CLABSI risk factors are multimodal, sulted from the changes in the electronic medical record. The IV
with risk at insertion and during management of CVADs. CLABSI Team continued to directly monitor tPA use daily, focusing on
reduction initiatives began at Hartford Hospital in 2007 with CVAD why was it given, interventions performed prior, and who is or-
rounding, huddles, and an Eyes on CVADs campaign. Founda- dering. Education of bedside nurses was instituted to improve
tional principles of a central line bundle consistent with practices that prevented occlusion. Education included training
recommendations were applied through hospital education of productive flushing with a push pause action that creates tur-
programs.55-57 After instituting education from 2007-2012, con- bulence and greater flush volume as needed. Bedside staff became
cerns over NC contamination were expressed as potentially accustomed to the new flushing practice and members of the IV
occurring during flushing practices, resulting in NC coloniza- Team evaluating catheter function before ordering of tPA. The
tion. Alcohol disinfection caps have been in use since 2010, bedside clinical staff has expressed appreciation for the IV Team
including compliance audits, but CLABSI rates spiked in 2012. efforts to help with troubleshooting occlusions, reducing medi-
Occlusion in conjunction with blood reflux and NCs had not been cation administration delays and time spent with assessment, thus
considered as a risk factor despite the connection between throm- giving clinicians more time to focus on taking care of patients.
botic occlusion and infection.58,59 In 1 study,41 the relative risk of
CLABSI associated with tPA use was 3 times that of patients who Limitations
did not receive tPA. Although there were variables and limita- This study has several limitations. First, the retrospective nature
tions within the study period, the results suggest that the subsequent of the data collection for baseline results may reflect inaccu-
change to antireflux NCs and limited tPA use resulted in CLABSI racies inherent in retrospective reviews. Measurement and
reduction to a low of 9 infections in the critical care unit for 2016. tabulation of results were from methods that incorporated
Continued research is needed to completely evaluate the influ- individual input, supply consumption data from material con-
ence of reflux and tPA on infection risk within CVADs. sumption and replacement of product, computer results of use
Hartford Hospital transitioned into a new electronic medical within pharmacy distribution, and a period of years where com-
record system during August 2016. With this transition, there was puter upgrades and software changes may compound
a temporary reduction in data input and control over tPA use moni- inaccuracies. Second, variables with multiple interventions in-
48 | JAVA | Vol 23 No 1 | 2018stituted and overlapping resulted in an inability to clearly indicate 9. Gorski L, Perucca R, Hunter M. Central venous access
the intervention and its direct influence. A series of interven- devices: care, maintenance, and potential complications. In:
tions initiated by the Healthcare Acquired Infection Committee Infusion Nursing: An Evidence-Based Approach. 3rd ed.
occurred during the application of the LSS process. Variables St Louis, MO: Saunders/Elsevier; 2010:495-515.
were reduced during the final 2 years as the IV Team took more 10. Hadaway L. Major thrombotic and nonthrombotic
direct responsibility for interventions and activities of assess- complications. Loss of patency. J Intraven Nurs.
ment, dressing changes, and complications management. 1998;21(suppl 5):S143-S160.
11. Valbousquet Schneider L, Duron S, Arnaud FX, et al.
Conclusions Evaluation of PICC complications in orthopedic inpatients
This Lean Thinking process with application of the Six Sigma with bone infection for long-term intravenous antibiotics
DMAIC and 5Ps principles resulted in significant sustained im- therapy. J Vasc Access. 2015;16:299-308.
provement for our facility. Staff communication, goal setting, 12. Hertzog D, Waybill P. Complications and controversies
and application of a process established a staff culture that is associated with peripherally inserted central catheters. J Infus
continually striving for better outcomes. The steps for defin- Nurs. 2008;31:159-163.
ing, measuring, analyzing, improving/implementing, and 13. Bartock L. An evidence-based systematic review of literature
controlling the system identified areas of deficiency for CVAD for the reduction of PICC line occlusions. J Assoc Vasc
occlusion management, flushing, and supply use. Reduced com- Access. 2010;15:58-63.
plications and cost savings provided value for the hospital. Of 14. O’Brien J, Paquet F, Lindsay R, Valenti D. Insertion of
greater importance was the reduction of treatment delays and PICCs with minimum number of lumens reduces
elimination of unnecessary medications and procedures. complications and costs. J Am Coll Radiol. 2013;10:864-
868.
Disclosure 15. Ullman A, Marsh N, Mihala G, Cooke M, Rickard C.
Lee Steere is part of the Nexus Medical Speakers Bureau and Complications of central venous access devices: a systematic
has received honorarium for speaking engagements. review. Pediatrics. 2015;136:e1331-e1344.
16. Smith S, Moureau N, Vaughn V, et al. Patterns and
Acknowledgment predictors of peripherally inserted central catheter occlusion:
The authors thank Nexus Medical LLC (Lenexa, KS) and ICU the 3P-O study. J Vasc Intervent Radiol. 2017;28:749-756.
Medical, Inc. (San Clemente, CA) for providing non-monetary 17. Mayo DJ. Reflux in venous access devices: a manageable
project support and Nancy Moureau, RN, PhD, CRNI, CPUI, problem. J Vasc Access Device. 2001;6:39-40.
VA-BC for assisting with editing of the manuscript. 18. Chauhan A, Ghigo J-M, Beloin C. Study of in vivo catheter
biofilm infections using pediatric central venous catheter
References implanted in rat. Nature Protocol. 2016;11:525-542.
1. Ernst F, Chen E, Lipkin C, Tayama D, Amin A. Comparison 19. Hadaway L, Richardson D. Needleless connectors: a primer
of hospital length of stay, costs, and readmissions of on terminology. J Infus Nurs. 2010;33:22-31.
alteplase versus catheter replacement among patients with 20. Elli S, Abbruzzese C, Cannizzo L, Lucchini A. In vitro
occluded central venous catheters. J Hosp Med. 2014;9:490- evaluation of fluid reflux after flushing different types of
496. needleless connectors. J Vasc Access. 2016;17:429-434.
2. Moureau N, Poole S, Murdock M, Gray S, Semba C. 21. Ferroni A, Gaudin F, Guiffant G, et al. Pulsative flushing
Central venous catheters in home infusion care: outcomes as a strategy to prevent bacterial colonization of vascular
analysis in 50,470 patients. J Vasc Intervent Radiol. access devices. Med Device (Auckland, NZ). 2014;7:379-
2002;13:1009-1016. 383.
3. Walshe L, Malak S, Eagan J, Sepkowitz K. Complication 22. Guiffant G, Durussel J, Merckx J, Flaud P, Vigier J, Mousset
rates among cancer patients with peripherally inserted central P. Flushing of intravascular access devices
catheters. J Clin Oncol. 2002;20:3276-3781. (IVADs)—efficacy of pulsed and continuous infusions. J
4. Wingerter L. Vascular access device thrombosis. Clin J Vasc Access. 2011;13:75-78.
Oncol Nurs. 2003;7:345-348. 23. Guiffant G, Durussel JJ, Flaud P, Vigier JP, Merckx J.
5. Jacobs BR. Central venous catheter occlusion and Flushing ports of totally implantable venous access devices,
thrombosis. Crit Care Clin. 2003;19:489-514. and impact of the Huber point needle bevel orientation:
6. Hardy G, Ball P. Clogbusting: time for a concerted approach experimental tests and numerical computation. Med Device
to catheter occlusions? Curr Opin Clin Nutr Metab Care. (Auckland, NZ). 2012;5:31-37.
2005;8:277-283. 24. Hadaway LC. Reopen the pipeline for I.V. therapy. Nursing.
7. Stephens LC, Haire WD, Kotulak GD. Are clinical signs 2005;35:54-61, quiz, 61-53.
accurate indicators of the cause of central venous catheter 25. Hadaway LC. Prevent occlusions with these flushing
occlusion? JPEN J Parenter Enter Nutr. 1995;19:75-79. pointers. Nursing. 2003;33:28.
8. Hill J, Broadhurst D, Miller K, et al. Occlusion management 26. Ahmed S, Manaf NH, Islam R. Effects of Lean Six Sigma
guidelines for CVAD. J Can Vasc Access Assoc. application in healthcare services: a literature review. Rev
2013;7(suppl 1):1-34. Environ Health. 2013;28:189-194.
2018 | Vol 23 No 1 | JAVA | 4927. Pocha C. Lean Six Sigma in health care and the challenge polyurethane and distal valve silicone peripherally inserted
of implementation of Six Sigma methodologies at a Veterans central catheters. J Vasc Interv Radiol. 2010;21:1191-
Affairs Medical Center. Qual Manag Health Care. 1196.
2010;19:312-318. 45. Hull G, Moureau N, Sengupta S. Quantitative assessment
28. Pronovost P, Armstrong C, Demski R, et al. Creating a of reflux in commercially available needleless IV connectors.
high-reliability health care system: improving performance J Vasc Access. 2017, Dec 4:0. DOI:10.5301/jva.5000781.
on core processes of care at Johns Hopkins Medicine. Acad 46. Jacobs B, Schilling S, Doellman D, Hutchinson N, Rickeym
Med. 2015;90:165-172. M, Nelson S. Central venous catheter occlusion: a
29. Daley AT. Pro: Lean Six Sigma revolutionizing health care prospective, controlled trial examining the impact of a
of tomorrow. Clin Leadersh Manag Rev. 2006;20:E2. positive-pressure valve device. JPEN J Parenter Enter Nutr.
30. de Koning H, Verver JP, van den Heuvel J, Bisgaard S, Does 2004;28:113-118.
RJ. Lean Six Sigma in healthcare. J Healthc Qual. 47. Jasinsky L, Wurster J. Occlusion reduction and heparin
2006;28:4-11. elimination trial using an antireflux device on peripheral and
31. DelliFraine JL, Langabeer JR 2nd, Nembhard IM. Assessing central venous catheters. J Infus Nurs. 2009;32:33-39.
the evidence of Six Sigma and Lean in the health care 48. Chopra V, Flanders S, Saint S, et al. The Michigan
industry. Qual Manag Health Care. 2010;19:211-225. Appropriateness Guide for Intravenous Catheters (MAGIC):
32. Evans JR, Lindsay WM. An Introduction to Six Sigma and results from a multispecialty panel using the RAND/UCLA
Process Improvement. Boston, MA: Cengage Learning; Appropriateness Method. Ann Intern Med. 2015;163(6
2014. suppl):S1-S40.
33. Bendell T, Penson R, Carr S. The quality gurus–their 49. Moureau N, Chopra V. Indications for peripheral, midline
approaches described and considered. Manag Serv Qual. and central catheters: summary of the MAGIC
1995;5:44-48. recommendations. Br J Nurs. 2016;25:S15-S24.
34. Callahan CD, Roberts TS. Performance measurement and 50. Jonker MA, Osterby KR, Vermeulen LC, Kleppin SM,
operations improvement using Lean Six Sigma. In: Practical Kudsk KA. Does low-dose heparin maintain central venous
Psychology in Medical Rehabilitation. New York, NY: access device patency? A comparison of heparin versus
Springer; 2017:569-573. saline during a period of heparin shortage. JPEN J Parenter
35. Shokri A, Shokri A. Quantitative analysis of Six Sigma, Enter Nutr. 2010;34:444-449.
Lean and Lean Six Sigma research publications in last two 51. Hostetter R, Nakasawa N, Tompkins K, Hill B. Precision
decades. Int J Qual Reliability Mgmt. 2017;34:598-625. in central venous catheter tip placement: a review of the
36. Moraros J, Lemstra M, Nwankwo C. Lean interventions in literature. J Assoc Vasc Access. 2010;15:112-125.
healthcare: do they actually work? A systematic literature 52. Steere L. Reduction in central venous catheter occlusions:
review. Int J Qual Health Care. 2016;28:150-165. impact of a pressure activated anti-reflux connector with
37. Bolton D. Preventing occlusion and restoring patency to a vascular access nurse algorithm in assessing occluded
central venous catheters. Br J Community Nurs. catheters. J Assoc Vasc Access. 2016;21:256-257.
2013;18:539-540. 53. Steere L. Examing the impact of proper central venous
38. Cummings-Winfield C, Mushani T. Restoring patency to access tip placement in preventing occlusions. J Assoc Vasc
central venous access devices. Clin J Oncol Nurs. Access. 2016;21:251.
2008;12:925. 54. Helm R, Klausner J, Klemperer J, Flint L, Huang E.
39. Gorski LA. Central venous access device occlusions: part Accepted but unacceptable: peripheral IV catheter failure.
1: thrombotic causes and treatment. Home Healthc Nurs. J Infus Nurs. 2015;38:189-203.
2003;21:115-121, quiz 122. 55. Marschall J, Mermel L, Fakih M, et al. Strategies to prevent
40. Hadaway L. Technology of flushing vascular access devices. central line-associated bloodstream infections in acute care
J Infus Nurs. 2006;29:137-145. hospitals: 2014 update. Infect Control Hosp Epidemiol.
41. Thakarar K, Collins M, Kwong L, Sulis C, Korn C, Bhadelia 2014;35:753-771.
N. The role of tissue plasminogen activator use and systemic 56. O’Grady N, Alexander M, Burns L, et al. Centers for
hypercoagulability in central line-associated bloodstream Disease Control and Prevention: guidelines for the
infections. Am J Infect Control. 2014;42:417-420. prevention of intravascular catheter-related infections. Clin
42. Rupp M, Sholtz L, Jourdan D, et al. Outbreak of Infect Dis. 2011;52:e162-e193.
bloodstream infection temporally associated with the use 57. O’Grady D, Parmentier D, Woltman J. The journey to zero.
of an intravascular needleless valve. Clin Infect Dis. J Contin Educ Nurs. 2012;43:199-200.
2007;44:1408-1414. 58. Raad II, Luna M, Khalil S-AM, Costerton JW, Lam C,
43. Khalidi N, Kovacevich DS, Papke-O’Donnell LF, Btaiche Bodey GP. The relationship between the thrombotic and
I. Impact of the positive pressure valve on vascular access infectious complications of central venous catheters. JAMA.
device occlusions and bloodstream infections. J Assoc Vasc 1994;271:1014-1016.
Access. 2009;14:84-91. 59. Mehall J, Saltzman D, Jackson R, Smith S. Fibrin sheath
44. Ong CK, Venkatesh SK, Lau GB, Wang SC. Prospective enhances central venous catheter infection. Crit Care Med.
randomized comparative evaluation of proximal valve 2002;30:908-912.
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